The surgeon forms his estimate of the size of the prostate by rectal examination. But sometimes a patient has retention of urine from enlarged prostate, when by this method of manual examination the amount of increase appears quite unimportant. The explanation is that the enlargement is chiefly confined to a small piece of the gland which protrudes like a tongue into the water-way. Robert McGill of Leeds was the first surgeon to remove by a supra-pubic operation this tongue-like process of new prostatic growth. Attempts had sometimes been made to get rid of it by instrumentation through the urethra, but they had not met with much success.
When the surgeon has made out the existence of an enlargement of the prostate, the next thing is to find to what extent this interferes with the bladder being emptied. To do this, he asks the patient to pass as much water as he is able, and then with due precautions introduces a soft catheter and measures the amount of urine which he thus draws off—half an ounce, an ounce, two ounces, however much it may be. It is this “residual urine” which causes the annoyance and the danger of enlarged prostate, and unless arrangements can be made for its regular withdrawal serious trouble is almost certain to ensue. The passing of a large catheter may have the effect of so opening up the water-way that, at any rate for a time, the irritability of the bladder may cease, in which case the patient may be instructed in the art of passing a catheter for himself. Or the surgeon may find that in addition to the regular passing of a large catheter an occasional washing-out of the bladder with hot boracic lotion is all that is needed in the way of active treatment. At the same time, however, the patient is placed upon a plain and wholesome diet with little or no alcohol, and he is instructed to lead in every respect a regular and quiet life. To many men with enlarged prostate the passing of an instrument night and morning is no great hardship, while to others the idea of leading what is called a “catheter life” appears intolerable, or, having for a time been patiently carried out, is found not only severely trying but greatly disappointing.
In some people the very first passing of a catheter sets up a local and constitutional disturbance, the bladder being rendered irritable and intolerant, the temperature going up, and shiverings and perspirations manifesting themselves. This condition was formerly called “catheter fever,” and was looked upon as something mysterious and peculiar. It is now generally understood to be the result of septic inoculation of the interior of the bladder.
Lastly, in other persons the passing of the catheter is attended with so much difficulty, distress or bleeding, that something more helpful and effectual is urgently called for.
Operative Treatment.—It has long been known that large tumours of the uterus sometimes dwindle if the ovaries are removed by operation, and Professor William White of Philadelphia thought that prostatic growths might be similarly influenced by the removal of the testicles. Beyond question considerable improvement has followed this operation in cases of enlargement of the prostate, especially where the enlargement seemed to be general, soft and vascular. A similar though perhaps a slower effect is produced when the duct of the testis, the vas deferens, is divided on each side of the body. If there is no great urgency about the case this treatment may well be tried, the bladder being all the while duly emptied by catheter and washed by irrigation. But if the case is urgent, there being difficulty or bleeding with the passing of the catheter, the bladder being excessively irritable and the urine foul, a more radical measure is needed. The best operation is that upon the lines laid down by Robert McGill, who opened the bladder through the anterior abdominal wall and removed that part of the prostate gland which was blocking the water-way. McGill’s operation was improved upon by Eugene Fuller of New York, who, in 1895, published a full account of his procedure.[1] Having opened the bladder from the front (as in supra-pubic lithotomy), he introduced his left index finger into the rectum and thrust the prostate gland towards the right index finger, which was then in the bladder. With the nail of that finger, or with the end of a pair of scissors, he made a rent in the mucous membrane of the bladder and the capsule of the gland, and then shelled out the mass of new tissue which had caused the prostatic enlargement. This operation is called “prostatectomy,” which means the removal of the prostate gland. The prostate gland, however, is not removed, but only a muscular and glandular mass (adenoma), which, growing within the prostatic capsule, encircles the urethra and squeezes the original gland tissue out of existence. Following on the lines of McGill and Fuller, P.J. Freyer has done excellent work in England towards placing this operation upon a sound basis.
Subsequently to the operation the bladder enjoys complete and needful rest, and the kidneys, which previously were in a condition of perpetual disturbance, improve in working power. The wound in the bladder and in the abdominal wall gradually closes; the function of the bladder returns, and the patient is soon able to go back to his usual occupation in greatly improved health and vigour. The operation is, necessarily, a serious one, and the age of the patient, the condition of his bladder, of his kidneys, and of his blood-vessels, require to be taken into consideration; still, the operation gives an excellent account of itself in statistics, and if a practical surgeon advises a patient to accept its risks his counsel may well be followed.
Malignant disease of the prostate is distinguished from senile glandular enlargement by the rapidity of its growth, by the freeness of the bleeding which is associated with the introduction of a catheter, and by the marked wasting which the individual undergoes. Unfortunately, by the time that the cancerous nature of the disease is definitely recognized, the prospect of relief being afforded by operation is small.
(E. O.*)
[1] Diseases of the Genito-urinary System, by Eugene Fuller, M.D. (London and New York, 1900).